Sclerotherapy-associated esophageal hematoma in a patient with myelofibrosis and portal hypertension.

A 71-year-old woman with primary myelofibrosis and esophageal varices was admitted for her first rubber band ligation procedure (platelet count, 58000/mm3; partial thromboplastin time, 33.4 seconds; international normalized ratio, 1.28). At endoscopy, the esophageal mucosa was extremely fragile and difficult to aspirate into the ligation device. Three of the six rubber bands placed at the gastroesophageal junction slipped off, leaving oozing blood. This was treated by injecting 3.5mL of polidocanol (Aethoxysklerol; Base Pharma, Gordon, NSW, Australia). During withdrawal of the endoscope, several areas with bluish bullous lesions (each<1cm in diameter) were observed in the upper two-thirds of the esophagus (●" Fig.1). One of these lesions, which showed slight oozing of blood, was injected with 1mL of polidocanol. Hematemesis developed 4 hours later, with a drop in the hemoglobin concentration of 0.8g/dL to 10.2g/dL. At secondlook endoscopy, the submucosal bullae involved up to half of the circumference of the esophagus and more than twothirds of its length (●" Fig.2a,b). One of these bullae had ruptured and was covered by a clot (●" Fig.2c). The rubber bands were still in place. There was no ongoing bleeding. Within the next 18 hours, the hemoglobin concentration decreased to 7.6g/dL, and the patient received two thrombocyte concentrates. At follow-up endoscopy after 6 weeks, the mucosa of the upper two-thirds of the esophagus was normal (●" Fig.3). Varices were still present in the lowest third. Intramural hematoma of the esophagus is a rare entity [1]. It may occur spontaneously; be secondary to a coagulopathy, as in myelofibrosis [2]; or develop after variceal sclerotherapy [3]. In our patient, low platelet counts, abnormal platelet function, sclerosis of the esophageal mucosa, and sclerotherapy may have been contributing factors. In summary, intramural hematoma of the esophagus is a rare complication that can result in severe blood loss. However, the prognosis is good with conservative management [4].